PRIVACY ACT MATERIAL REMOVED
GOVERNSMINT OF
Majuro,
MARS WALL ISLANDS
Marshall
Tslands
Special Heaitn Survey
Name
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Sex
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age JJ.
nesicence:
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1960-1966 — (..,
1965-1972 _ }y¢4
1972-
Snort caescription of symptoms:
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Year
-£¥2 you been receiving treatment for any illness for a perios
.
«2 ONG year?
(
on.» anyone in your family complained. of similiar SYMP LORS to une
ones you are now experiencing? (_.
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surgery?fo.
Signature-
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EEE
Date
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PRIVACY ACT MATERIAL REMOVED